New Patient · My Private Clinic

Register as a Patient

Complete the form below to create your patient record before your first appointment.

Step 1 of 6 · Personal Details

Personal Details

Title *

First name *

Last name *

Date of birth *

/ /

NHS number (optional) Found on your NHS app or medical letters

Sex *

Male Female Prefer not to say

Email address * Confirmation sent here

Phone / WhatsApp *

Search for address

Enter your postcode or the first line of your address

Address line 1 *

Address line 2 (optional)

Town / City *

Postcode *

We use this to access your NHS records (with your consent) and for referral letters.

Search for your surgery *

Type at least 2 characters to search

Your usual GP (optional) The GP you normally see at this surgery

This helps Dr Secretary prepare for your appointment. All fields are optional.

Significant medical conditions (optional)

Current medications Not currently taking any medications

Drug allergies No known drug allergies

Someone we can contact in an emergency.

Full name *

Relationship *

Phone number *

Please read and confirm the following before submitting your registration.

Your information is held securely in compliance with UK GDPR.